We have studied the occurrence of dual diagnoses (psychoses as well as abuse of either amphetamine, cannabis or opiates) during a 15-year period, among patients treated at Huddinge Hospital, Stockholm, Sweden. The purpose of the study is to evaluate if the different drugs were coupled to different rates of psychiatric co-morbidity. During the period in question, 461, 425 and 371 different patients respectively had been admitted at least once due to dependency on amphetamine, cannabis and opiates. Approximately 30% of the patients with a pure abuse of amphetamine or cannabis and less than 6% of the opiate abusers had been diagnosed at least once with any of the psychoses studied. Comparing the frequency of psychoses among mixed and pure abusers of illegal drugs, with and without a concomitant abuse of alcohol, we found that the co-morbidity rate for mixed opiate abusers increased significantly from 7.2 to 20.2% when alcohol abuse was also present. For abusers of amphetamine and cannabis (both pure and mixed), no differences in co-morbidity rates were seen when an abuse of alcohol was added to that of the drugs. It is difficult to find an explanation for the significant difference between the co-morbidity of pure abuse of amphetamine or cannabis on the one hand and opiates on the other. In conclusion, our findings show that the distribution of psychotic illness is high among abusers of amphetamine and cannabis, in contrast to the generally lower co-morbidity among abusers of opiates. Although these findings are consistent with earlier studies that have shown a propensity for developing psychoses among abusers of amphetamine and cannabis, one should bear in mind that this study is based on inpatients, and is not necessarily representative for all abusers of the drugs in question.

There is currently no simple and morbidity-free procedure available to determine opiate dependence in patients. There is preliminary evidence, however, that the naloxone conjunctival test may be useful in this regard. This test consists of instilling a drop of saline solution of naloxone hydrochloride (an opiate-receptor antagonist) into the subject's eye. This causes significant homolateral mydriasis (anisocoria) in the eye of a chronic opioid-dependent subject and not in that of a non-dependent subject. We reviewed the international literature on the naloxone conjunctival test using the Medline database and a manual search of major scientific journals specialized in the field of substance abuse. Up to March 1995, we identified six articles dealing specifically with the use of opiate antagonist ophthalmic solutions in populations of chronic opioid addicts. Four of the articles reported the occurrence of mydriasis when a solution of naloxone is used in opioid addicts. Two of the articles reported that there was no differential change in pupil size when the naloxone solution is used; however, one study used a much weaker and the other a much stronger solution of naloxone than reported in the other studies. From our review of the literature, it appears that the naloxone conjunctival test holds great promise as a simple and morbidity-free method of testing for chronic opioid addiction and, therefore, it should be studied further and its usage eventually developed.

Buprenorphine is a partial μ-opioid receptor agonist that is being increasingly used in clinical practice in the treatment of opioid dependence in the UK, USA, and, elsewhere. Its unique pharmacological properties mean it is a relatively safe drug, it can be given by alternate day dispensing, and it is associated with relatively mild symptoms on withdrawal. The interpretation of the research literature on buprenorphine is however, complex, and often appears to be in conflict with how buprenorphine is used in clinical practice. This article describes these apparent contradictions, their likely explanations, and how these may further inform our clinical practice. The article also describes the clinically relevant pharmacological properties of buprenorphine, compares it to methadone, relates the evidence to clinical experience, and provides practical advice on how to manage the most common clinical techniques. The best quality evidence suggests that very rapid buprenorphine induction is not associated with a higher drop-out rate than methadone, that buprenorphine is probably as good as methadone for maintenance treatment, and is superior to methadone and α-2 adrenergic agonists for detoxification. However, buprenorphine cannot yet be considered the ‘gold standard’ treatment for opiate dependence because of the higher drop-out rates that may occur on induction using current techniques, its high-cost relative to methadone, and because the place of buprenorphine in treatment is still continuing to evolve.

This article presents empirical data on the limited availability of hospice and palliative care to the 6 million people of the English-speaking Caribbean. Ten of the 13 nations therein responded to a survey and reported employing a total of 6 hospice or palliative specialists, and having a total of 15 related facilities. The evolving socioeconomic and cultural context in these nations bears on the availability of such care, and on the willingness to report, assess, and prioritize pain, and to prescribe opiates for pain. Socioeconomics and culture also impinge on what medications and modalities of care are routinely available for pain or other conditions and can challenge professionalism, empathy, and responsiveness to patients’ unrelieved pain. Although all respondents report having a protocol for pain management, hospice, or end-of-life care, their annual medical use of opiates is well below the global mean. The International Narcotics Control Board (INCB), which monitors such use, encourages Caribbean and other low- and middle-income countries to increase their use of opiates to treat pain, and to overcome both unfounded fears of addiction and overly restrictive interpretation of related laws and regulations. Contextual considerations like those described here are important to the success of policies and capacity-building programs aiming to increase access to hospice and palliation, and perhaps to improving other aspects of health and healthcare. Exploring and responding to the realities of socioeconomic and cultural conditions will enhance public and policy dialogue and improve the design of interventions to increase access to palliative and hospice care. Improving access to palliative and hospice care in the Caribbean demonstrates beneficence and helps to fulfill human rights conventions.

Recent findings have identified an endogenous brain system mediating the actions of cannabis sativa preparations. This system includes the brain cannabinoid receptor (CB-1) and its endogenous ligands anandamide and 2-arachidonoyl-glycerol. The endogenous cannabinoid system is not only present in the adult brain, but is also active at early stages of brain development. Studies developed at our laboratory have revealed that maternal exposure to psychoactive cannabinoid results in neuro-developmental alterations. A model is proposed in which early Δ9-tetrahydrocannabinol (THC) exposure during critical developmental periods results in permanent alterations in brain function by either the stimulation of CB-1 receptors present during the development, or by the alterations in maternal glucocorticoid secretion. Those alterations will be revealed in adulthood after challenges either with drugs (i.e. opiates) or with environmental stressors (i.e. novelty). They will include a modified pattern of neuro-chemical, endocrine, and behavioral responses that might lead ultimately to inadaptation and vulnerability to opiate abuse.

Objectives: While treatment is known to improve drug and crime outcomes for opiate users, there is debate in the literature about the longitudinal effects of substance misuse and the comorbidity of mental health problems. We sought to describe and model anxiety and depression outcomes during opiate substance misuse treatment.

Methods: The first national, longitudinal treatment outcome study of 404 opiate users entering a new episode of inpatient or outpatient treatment and followed up at one and three years and assessed using the Maudsley Addiction Profile instrument.

Results: A total of 404 opiate users were recruited representing approximately 8.2% of all new treatments and 17% of all new methadone treatments at national level in Ireland in 2003. At three years 97% (n = 392) were followed-up. At one year, analysis revealed the odds of experiencing depression was between five and 15 times the odds for opiate users who also used cocaine than non cocaine using opiate users, but this had decreased at three years. At three years those who were drug free, that is, not in treatment and not using illicit drugs, were less likely to experience feeling hopeless about the future than those in treatment or those not in treatment and using, but they were also more likely to experience feeling tense. Those in treatment were more likely to feel lonely.

Conclusion: The concurrent misuse of cocaine and other substances during opiate treatment and the stage of the treatment pathway are associated with anxiety and depression among opiate users in treatment. These client factors need to be considered when implementing individualised treatment care plans.

One subpopulation of amacrine in the turtle retina was shown to contain met-enkephalin by means of immunocytochemistry, and another was demonstrated to have a high-affinity uptake system for [3H]-dopamine by means of tutoradiography. Although the amacrine soma size, density, and distribution of their neurites in IPL substrata was similar in retinas in which met-enkephalin and dopamine were localized, combined light microscope immuncytochemistry-autoradiography demonstrated that these two neurotransmitter systems did not coexist in the same cells. Because the two amacrine cell subtypes ramify in the same IPL substrata, neuronal interaction between them is possible. Release experiments showed that the potassium-induced release of [3H]-dopamine from the superfused turtle retina was reduced by 40% when enkephlian was added to the superfusate. The inhibition of [3H]-dopamine release could be blocked by the addition of naloxone. The addition of enkephalin had no effect of the potassium-induced release of [3H]-GABA from the superfused retina. These findings suggest that an enkephalinergic modulation of the dopaminergic amacrine cell system exits in the turtle retina.

Objectives: To describe the psychosocial and clinical characteristics of children referred to a community-based child and adolescent mental health service, whose mothers reported that they took opiates during the pregnancy.

Methods: In a retrospective study, the case notes of all children whose mothers reported that they had been exposed to opiates in utero, and who were referred to the Department of Child and Family Psychiatry, Mater Hospital, between 2001–2003, were identified by maternal reports. Information was obtained on age, gender, referral source, socio-economic group, family type, number of siblings, involvement of community care services, nature of presenting problems, diagnosis, interventions offered, and treatment difficulties. Information was recorded anonymously.

Results: 15 children were identified, of whom nine were male. Most were found to be living with their mother alone or with their mother and a partner, and to be socially and financially disadvantaged. Their presenting complaints usually involved combinations of aggressive, hyperactive, and oppositional behaviour. Diagnoses included ADHD, a speech and language disorder, and an axis II disorder. Interventions were frequently unsuccessful because of parents' difficulties with attending appointments, and because of instability in the families' living arrangements.

Conclusions: These children, due to a complex interplay of biological and psychosocial adversity, are at serious risk of ongoing psychiatric disorders in childhood and adolescence, and for adverse outcomes in adult life. A prospective cohort study of all children born to opiatedependent mothers is necessary to quantify the level of risk and identify resilience factors.